Author + information
- S1936879816314820-aa5ec5a787ac7d5511701b741c08c791Paari Dominic, MD∗ ( and )
- S1936879816314820-d8a14e19c1577287ce64b9b53d00996bGeorge Mina, MD
- ↵∗Section of Cardiology, Department of Medicine, LSUHSC Shreveport, 1501 Kings Highway, Shreveport, Louisiana 71103
We thank Dr. Danzi for his interest in our article regarding the effect of access site and anticoagulation regimens on outcomes of patients with acute coronary syndrome (1). Although we agree with Dr. Danzi, that the p value for interaction was not statistically significant when bleeding outcome of bivalirudin versus heparin was stratified by access site. Additional published and unpublished findings validates our unmoderated interpretation. First, the HEAT PPCI (How Effective Are Antithrombotic Therapies in Primary Percutaneous Coronary Intervention) trial (2), which included 81% radial access patients, showed absence of any benefit with bivalirudin, implying that radial access use masked the bleeding-lowering benefit with bivalirudin. We excluded HEAT PPCI due to our stringent inclusion criteria, and we could not obtain access specific bleeding outcomes data from the authors. Although patients with femoral access patients were included in the trial, when we include the bleeding outcomes from HEAT PPCI in the meta-analysis, the bleeding-lowering effect of bivalirudin remains comparable with heparin in radial access patients (odds ratio, 0.84; 95% confidence interval, 061 to 1.15; p = 0.28), and the p value for interaction (access site and bleeding) becomes statistically significant (p = 0.005), suggesting that bleeding outcomes do differ between access site subgroups. Another meta-analysis by Mahmoud and Elgendy (3) included HEAT PPCI in their analysis and suggested absence of significant bleeding lowering effect of bivalirudin when radial access is used.
Second, our findings are in agreement with a comprehensive network analysis performed by Rao and Shah (4), who used data from a larger number of studies to show that the bleeding lowering benefit of bivalirudin did not reach statistical significance in radial access patients. Third, as mentioned in our study, the only trial that randomized patients based on anticoagulation and access site was the MATRIX trial (Minimizing Adverse haemmhorragic events by TRansradial access site and AngioX study) and that showed absence of a statistically significant effect of bivalirudin when radial access was used (5).
Therefore, based on the data we have to date, it seems that the bleeding-lowering benefit with bivalirudin is markedly attenuated when radial access is used and, therefore, using heparin in those patients is probably not unreasonable. In contrast, if the operator chooses to use femoral access, then bivalirudin is likely superior to heparin in those patients. Finally, whether radial access or bivalirudin is a better bleeding lowering strategy, we agree with Danzi that the evidence behind better outcomes with radial access is stronger than that with bivalirudin, especially when glycoprotein IIb/IIIa inhibitors are not routinely used with heparin. However, this determination was outside the scope of our study.
Please note: Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Mina G.S.,
- Gobrial G.F.,
- Modi K.,
- Dominic P.
- Mahmoud A.N.,
- Elgendy I.Y.
- Rao S.V.,
- Shah R.